Get Sick, Go Bankrupt and Die

Let’s be honest: Despite his reputation as a maverick, John McCain spent most of his last decade being a very orthodox Republican, toeing the party line no matter how irresponsible it became. Think of the way he abandoned his onetime advocacy of action to limit climate change.

But he redeemed much of that record with one action: He cast the crucial vote against G.O.P. attempts to repeal the Affordable Care Act. That single “nay” saved health care for tens of millions of Americans, at least for a while.

But now McCain is gone, and with him, as far as we can tell, the only Republican in Congress with anything resembling a spine. As a result, if Republicans hold Congress in November, they will indeed repeal Obamacare. That’s not a guess: It’s an explicit promise, made by Vice President Mike Pence last week.

But what about the problems that sank the repeal effort in 2017? Surely Republicans have spent the past year rethinking their policy ideas, trying to come up with ways to undo the A.C.A. without inflicting enormous harm on ordinary Americans, especially those with pre-existing medical conditions. Right?

See, I made a joke.

Of course, Republicans haven’t rethought their ideas on health care (or, actually, anything else). Partly that’s because the modern G.O.P. doesn’t do policy analysis. Democrats have a network of think tanks and sympathetic independent experts who look hard at evidence, try to devise solutions to real problems and sometime affect actual legislative proposals. Republicans have nothing comparable; their tame “experts” are basically in the business of saying whatever their political masters want to hear.

In the case of health care, however, there’s an even deeper problem: The G.O.P. can’t come up with an alternative to the Affordable Care Act because no such alternative exists. In particular, if you want to preserve protection for people with pre-existing conditions — the health issue that matters most to voters, including half of Republicans — Obamacare is the most conservative policy that can do that. The only other options are things like Medicare for all that would involve moving significantly to the left, not the right.

Health economists have explained this point many times over the years; but as always, it’s difficult to get a man to understand something when his salary depends on his not understanding it. Still, let’s try one more time.

If you want private insurers to cover people with pre-existing conditions, you have to ban discrimination based on medical history. But that in itself isn’t enough, because if policies cost the same for everyone, those who sign up will be sicker than those who don’t, creating a bad risk pool and forcing high premiums. That was the case in New York, where premiums for individual policies were very high before the A.C.A. — and promptly fell by half when Obamacare went into effect.